In Part 2, let’s see what the evidence (1) says about dairy, wheat, high fibre food and FODMAPs.
Should I restrict milk and dairy? Would that help with my IBS?
There was a high risk of bias reported for the studies included in the review. They were not randomised controlled trials, so the effects could have only been observed without definite conclusions about lactose malabsorption in adults with IBS.
There is no high-quality evidence to confirm that milk and dairy-free diet can alleviate IBS symptoms.
What this highlights though is that lactose intolerance, lacking enzyme to break down milk sugar, can be mixed up with IBS. Lactose intolerance needs to be ruled out first. If inability to absorb lactose is due to IBS, eliminating milk and dairy can only result in small benefit, as the review highlights. The evidence we have is far form definite and convincing.
This leads back to self-awareness and tolerance levels. Having a small cup of natural yoghurt with strawberries (note: low FODMAP fruit), in theory, should not do any harm and would ensure you are getting about 200mg of calcium out of 700mg of minimum recommended average intake for healthy adults. Calcium dose for individuals with Inflammatory Bowel Disease or Coeliac Disease is even higher. However, we are all different, so check with yourself first.
Is gluten-free the solution for IBS?
Gluten is a protein found in wheat, rye and barley. It is not clear if gluten causes IBS-type symptoms directly. The review suggests that reduced intake of gluten might improve symptoms such as abdominal pain, tiredness and stool consistency, but going gluten-free might not be be-all-end-all solution.
Gluten free diet is a quite expensive pleasure if you were to consume all your regularly eaten products to gluten-free variety. That is where whole foods may be a way to go, instead of changing your bread to gluten free bread, you could try potatoes or chickpeas as a side dish. Also, if reducing the obvious choices of gluten, remember that gluten can be hidden in processed foods, such as gravy or salad dressing. More information on that can be found here.
What's the fuss about high fibre food?
If you are constipated, you should increase your fibre intake. If you are having diarrhoea, fibre intake should go down. Simple, right?
First, what is fibre anyway? Fibre is an umbrella term for complex carbohydrate structures which are known to pass through your digestive tract without being absorbed. It can be classified to soluble and insoluble types based on the ability to be soluble and fermentable in water. Sources of both types of fibre include cereal grains such as wheat, oats, barley; fruit and vegetables; legumes, pulses and seeds (2).
Now, the premise for treating constipation with having more fibre lies on the fact that bacteria in the gut feeds on the fibre and that has positive effects on gut flora. Happy gut = regular bowel movements.
Too much fibre can be not so good for your gut – bacterial overgrowth is another issue. You probably heard about SIBO (Small Intestine Bacterial Overgrowth) already.
‘How much is too much?’ you might ask. Well, new SACN guidelines advise 30g of fibre/day for healthy population even though we are not even meeting previous recommendations. This recommendation applies to IBS sufferers as well. Women need 25g of fibre/day.
Linseeds are often quoted to be great in improving IBS. Some advocate ground and others say whole linseeds are good. Well, if you are grounding your linseeds believing that it is better – stop because the evidence is conflicting. One study found that supplementing with ground or whole linseeds v placebo supplementation showed no benefit (3). Another study, showed that 6-24g of ground linseeds helped with reducing constipation and abdominal bloating when taken for over 3 months (4).
Note of caution for linseed supplementation if you believe it helps with your symptoms - the dose has to be introduced gradually: start with 4g (1 tsp) and slowly increase up to 24g/day being aware of what the dose is doing for you IBS. Another thing to remember is for fibre to do its job you have to be well hydrated. So, sprinkling linseeds on oat porridge, yoghurt, cereal, soup, salad might be a good idea, since these contain water.
Psyllium husk, as another alternative remedy, cannot be definitely claimed to improve IBS and IBS-C symptoms. There is simply insufficient evidence to give such claims (5).
OK, what about FODMAPs?
It has become a dietary trend these days to talk about low FODMAP foods. There is growing evidence to say that low FODMAP diet is beneficial in managing IBS. FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols. In other words, a form of sugar/carbohydrates which are fermented in your small intestine.
It’s a topic in itself to talk about. The review suggests that low FODMAP diet is beneficial when supervised by a dietitian. Like with any other diet, the more consistent and strict you are with sticking to it – the greater the benefits. If you can’t stick to it, it was, in fact, suggested that following traditional health eating advice (6) or using a probiotic with L. rhamnosus GG strain, can be just as good (7).
Few things to be aware of, are lower fibre intake compared to habitual dietary intake on low FODMAP diet and lower calcium intake over short-term (8).
So, now what?
The evidence we have is not great. So, if you wanted concrete answers, it is not available yet and better quality research needs to be done to confirm current observations. This leaves us with practice of self-awareness. Identifying foods you react to is key, reducing the intake and then slowly reintroducing the amounts again to see if they are really causing your symptoms is key. You don't want to experiment with elimination of food products for a prolonged period of time as there is a risk of developing micronutrient deficiency and even creating energy deficit by eliminating a food group altogether and not balancing out the diet.
The takeaway message from is: be cautious about elimination of foods (you don't want to end up following a fad diet) and take care of yourself as you are here for the long run. Understanding your IBS and working with it is the way to go.
1. IBS Dietetic Guideline Review Group on behalf of Gastroenterology Specialist Group of the British Dietetic Association (2016) British Dietetic Association systematic review of systematic reviews and evidence-based practice guidelines for the use of probiotics in the management of irritable bowel syndrome in adults (2016 update). Journal of Nutrition and Dietetics. 29(5), pp. 549- 575.
2. Dhingra, D., Michael, M., Rajput, H. and Patil, R.T. (2012) Dietary fibre in foods: a review. Journal of Food Science and Technology. 49(3), pp. 255–266.
3. Cockerell KM, Watkins AS, Reeves LB et al. (2012) Effects of linseeds on the symptoms of irritable bowel syndrome: a pilot randomised controlled trial. Journal of Human Nutrition and Dietetics. 25, 435–443.
4. Tarpila, S., Tarpila, A., Grohn, P., Silvennoinen, T., Lindberg, L. (2004) Efficacy of ground flaxseed on constipation in patients with irritable bowel syndrome. Current Topics in Nutraceutical Research. 2, pp. 119–125.
5. Bijkerk, C.J., de Wit, N.J., Muris, J.W.,Whorwell, P.J., Knottnerus, J.A., Hoes, A.W. (2009) Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial. BMJ. 339.
6. Bohn, L., Storsrud, S., Liljebo, T., Collin, L., Lindfors, P., Tornblom, H., Simren, M. (2015) Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial. Gastroenterology. 149, pp. 1399–1407.
7. Pedersen, N., Andersen, N.N., Vegh, Z., Jensen, L., Ankersen, D.V., Felding, M., Simonsen, M.H., Burisch, J. and Munkholm, P. (2014) Ehealth:low FODMAP diet vs Lactobacillus rhamnosus GG in irritable bowel syndrome. World Journal of Gastroenterology. 20, pp. 16215–16226.
8. Staudacher, H.M., Lomer, M.C.E., Anderson, J., Barrett, J.S., Muir, J.G., Irving, P.M. and Whelan, K. (2012) Fermentable Carbohydrate Restriction Reduces Luminal Bifidobacteria and Gastrointestinal Symptoms in Patients with Irritable Bowel Syndrome. The Journal of Nutrition. 142(8), pp. 1510-1518.
Should I restrict milk and dairy? Would that help with my IBS?
There was a high risk of bias reported for the studies included in the review. They were not randomised controlled trials, so the effects could have only been observed without definite conclusions about lactose malabsorption in adults with IBS.
There is no high-quality evidence to confirm that milk and dairy-free diet can alleviate IBS symptoms.
What this highlights though is that lactose intolerance, lacking enzyme to break down milk sugar, can be mixed up with IBS. Lactose intolerance needs to be ruled out first. If inability to absorb lactose is due to IBS, eliminating milk and dairy can only result in small benefit, as the review highlights. The evidence we have is far form definite and convincing.
This leads back to self-awareness and tolerance levels. Having a small cup of natural yoghurt with strawberries (note: low FODMAP fruit), in theory, should not do any harm and would ensure you are getting about 200mg of calcium out of 700mg of minimum recommended average intake for healthy adults. Calcium dose for individuals with Inflammatory Bowel Disease or Coeliac Disease is even higher. However, we are all different, so check with yourself first.
Is gluten-free the solution for IBS?
Gluten is a protein found in wheat, rye and barley. It is not clear if gluten causes IBS-type symptoms directly. The review suggests that reduced intake of gluten might improve symptoms such as abdominal pain, tiredness and stool consistency, but going gluten-free might not be be-all-end-all solution.
Gluten free diet is a quite expensive pleasure if you were to consume all your regularly eaten products to gluten-free variety. That is where whole foods may be a way to go, instead of changing your bread to gluten free bread, you could try potatoes or chickpeas as a side dish. Also, if reducing the obvious choices of gluten, remember that gluten can be hidden in processed foods, such as gravy or salad dressing. More information on that can be found here.
What's the fuss about high fibre food?
If you are constipated, you should increase your fibre intake. If you are having diarrhoea, fibre intake should go down. Simple, right?
First, what is fibre anyway? Fibre is an umbrella term for complex carbohydrate structures which are known to pass through your digestive tract without being absorbed. It can be classified to soluble and insoluble types based on the ability to be soluble and fermentable in water. Sources of both types of fibre include cereal grains such as wheat, oats, barley; fruit and vegetables; legumes, pulses and seeds (2).
Now, the premise for treating constipation with having more fibre lies on the fact that bacteria in the gut feeds on the fibre and that has positive effects on gut flora. Happy gut = regular bowel movements.
Too much fibre can be not so good for your gut – bacterial overgrowth is another issue. You probably heard about SIBO (Small Intestine Bacterial Overgrowth) already.
‘How much is too much?’ you might ask. Well, new SACN guidelines advise 30g of fibre/day for healthy population even though we are not even meeting previous recommendations. This recommendation applies to IBS sufferers as well. Women need 25g of fibre/day.
Linseeds are often quoted to be great in improving IBS. Some advocate ground and others say whole linseeds are good. Well, if you are grounding your linseeds believing that it is better – stop because the evidence is conflicting. One study found that supplementing with ground or whole linseeds v placebo supplementation showed no benefit (3). Another study, showed that 6-24g of ground linseeds helped with reducing constipation and abdominal bloating when taken for over 3 months (4).
Note of caution for linseed supplementation if you believe it helps with your symptoms - the dose has to be introduced gradually: start with 4g (1 tsp) and slowly increase up to 24g/day being aware of what the dose is doing for you IBS. Another thing to remember is for fibre to do its job you have to be well hydrated. So, sprinkling linseeds on oat porridge, yoghurt, cereal, soup, salad might be a good idea, since these contain water.
Psyllium husk, as another alternative remedy, cannot be definitely claimed to improve IBS and IBS-C symptoms. There is simply insufficient evidence to give such claims (5).
OK, what about FODMAPs?
It has become a dietary trend these days to talk about low FODMAP foods. There is growing evidence to say that low FODMAP diet is beneficial in managing IBS. FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols. In other words, a form of sugar/carbohydrates which are fermented in your small intestine.
It’s a topic in itself to talk about. The review suggests that low FODMAP diet is beneficial when supervised by a dietitian. Like with any other diet, the more consistent and strict you are with sticking to it – the greater the benefits. If you can’t stick to it, it was, in fact, suggested that following traditional health eating advice (6) or using a probiotic with L. rhamnosus GG strain, can be just as good (7).
Few things to be aware of, are lower fibre intake compared to habitual dietary intake on low FODMAP diet and lower calcium intake over short-term (8).
So, now what?
The evidence we have is not great. So, if you wanted concrete answers, it is not available yet and better quality research needs to be done to confirm current observations. This leaves us with practice of self-awareness. Identifying foods you react to is key, reducing the intake and then slowly reintroducing the amounts again to see if they are really causing your symptoms is key. You don't want to experiment with elimination of food products for a prolonged period of time as there is a risk of developing micronutrient deficiency and even creating energy deficit by eliminating a food group altogether and not balancing out the diet.
The takeaway message from is: be cautious about elimination of foods (you don't want to end up following a fad diet) and take care of yourself as you are here for the long run. Understanding your IBS and working with it is the way to go.
1. IBS Dietetic Guideline Review Group on behalf of Gastroenterology Specialist Group of the British Dietetic Association (2016) British Dietetic Association systematic review of systematic reviews and evidence-based practice guidelines for the use of probiotics in the management of irritable bowel syndrome in adults (2016 update). Journal of Nutrition and Dietetics. 29(5), pp. 549- 575.
2. Dhingra, D., Michael, M., Rajput, H. and Patil, R.T. (2012) Dietary fibre in foods: a review. Journal of Food Science and Technology. 49(3), pp. 255–266.
3. Cockerell KM, Watkins AS, Reeves LB et al. (2012) Effects of linseeds on the symptoms of irritable bowel syndrome: a pilot randomised controlled trial. Journal of Human Nutrition and Dietetics. 25, 435–443.
4. Tarpila, S., Tarpila, A., Grohn, P., Silvennoinen, T., Lindberg, L. (2004) Efficacy of ground flaxseed on constipation in patients with irritable bowel syndrome. Current Topics in Nutraceutical Research. 2, pp. 119–125.
5. Bijkerk, C.J., de Wit, N.J., Muris, J.W.,Whorwell, P.J., Knottnerus, J.A., Hoes, A.W. (2009) Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial. BMJ. 339.
6. Bohn, L., Storsrud, S., Liljebo, T., Collin, L., Lindfors, P., Tornblom, H., Simren, M. (2015) Diet low in FODMAPs reduces symptoms of irritable bowel syndrome as well as traditional dietary advice: a randomized controlled trial. Gastroenterology. 149, pp. 1399–1407.
7. Pedersen, N., Andersen, N.N., Vegh, Z., Jensen, L., Ankersen, D.V., Felding, M., Simonsen, M.H., Burisch, J. and Munkholm, P. (2014) Ehealth:low FODMAP diet vs Lactobacillus rhamnosus GG in irritable bowel syndrome. World Journal of Gastroenterology. 20, pp. 16215–16226.
8. Staudacher, H.M., Lomer, M.C.E., Anderson, J., Barrett, J.S., Muir, J.G., Irving, P.M. and Whelan, K. (2012) Fermentable Carbohydrate Restriction Reduces Luminal Bifidobacteria and Gastrointestinal Symptoms in Patients with Irritable Bowel Syndrome. The Journal of Nutrition. 142(8), pp. 1510-1518.
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